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KChan Saves the World > KC OB > Flashcards

KC OB Flashcards

1
Q

*Pregnant woman 32 weeks with uterine tenderness, uterine firmness and vaginal bleeding: 4 Ddx

A
  • Placental abruption
  • Placenta previa
  • Early labor (bloody show)
  • Cervical/vaginal lesion
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2
Q

*Pregnant woman 32 weeks with uterine tenderness, uterine firmness and vaginal bleeding: would you do a spec? Why or why not?

A

Digital or instrumental probing of cervix should be avoided until the diagnosis of placenta previa is excluded by ultrasound as severe bleeding can be precipitated

Speculum exam should only be performed in those settings in which obstetric consultation is not readily available

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3
Q

*How sensitive is ultrasound for detecting placental abruption? Give a number.

A

Per UpToDate: “The sensitivity of ultrasound findings for diagnosis of abruption is only 25 to 60 percent”

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4
Q

*Pregnant woman 32 weeks with uterine tenderness, uterine firmness and vaginal bleedin: She becomes hypotensive and unstable. 4 management at this point

A
  • IV crystalloid resuscitation
  • Administration of blood products (umatched O negative blood, unless group and screen done)
  • OB/GYN consultation
  • Fetal monitoring
  • Correction of coagulopathy
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5
Q

*List three medications to treat high blood pressure in preeclampsia

A

Per SOGC:
• Labetolol, start with 20 mg IV
• Nifedipine, 5 to 10 mg capsule
• Hydralazine, start with 5 mg IV

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6
Q

*What 4 lab tests would you order in a patient with pre-eclampsia?

A

CBC
LFTs
Creatinine
Urinalysis
Coag

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7
Q

*2 antihypertensive medications (or class) contraindicated in 1st trimester, and what congenital disorder they are associated with?

A

ACEi, ARB - Potter’s syndrome (renal agenesis) … I think this is what theyre asking for

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8
Q

*5 RF for ectopic pregnancy

A

Anatomic/surgical abnormaliti- Anatomic/surgical abnormalities: previous ectopic, prior tubal surgery (sterilization or ectopic), pelvic surgery with pelvic adhesions,
Conception: IUD, in vitro fertilization, infertility, previous abortion/miscarriage
Patient: PID, smoking, endometriosis, advanced agees: previous ectopic, prior tubal surgery (sterilization or ectopic), pelvic surgery with pelvic adhesions,

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9
Q

*What are 4 findings on ultrasound to diagnose an IUP?

A
  • Intrauterine decidual reaction and gestational sac
  • Intrauterine yolk sac
  • Intrauterine fetal heart activity
  • Myometrial mantle of at least 5 mm
  • Uterine-bladder juxtaposition
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10
Q

*2 finding on ultrasound suggestive of ectopic pregnancy?

A

Extrauterine gestational sac, yolk sac, fetal pole, or cardiac activity
Pseudo-gestational sac, a gestational sac without a yolk sac
If patient unstable:
Intra-abdominal free fluid

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11
Q

*What are two management priorities in unstable ruptured ectopic?

A

IV fluids/blood
Immediate surgery

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12
Q

*When in pregnancy does the risk of PID substantially decrease?

A

PID is very rare in pregnancy and does not occur after the first trimester.

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13
Q

*32 weeks G1P0 with BP 230/115 and severe refractory headache. Presumptive diagnosis? 2 medications for her at this time?

A

Pre-eclampsia
1. Mg&raquo_space;> labetalol
2. Steroids for baby

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14
Q

*5 risk factors Pregnancy-Induced Hypertension (Preeclampsia and Eclampsia)

A

The risk of pregnancy-induced hypertension is greatest in women:
- Pregnancy: primigravida, new partners,multiple gestation, extremes of maternal age <18 or >35
- Pre-existing: HTN, renal disease, diabetes, antiphospholipid syndrome, obesity
- Hx of the same, previous HTN in pregnancy, family hx of pregnancy induced hypertension

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15
Q

*In a woman with RUQ pain and pregnancy how would you distinguish based on BW AFLP versus HELPP?

A
  1. AFLP has raised LFTs with normal platelets, Cr also often raised
  2. HELLP has low platelets
    3 Transaminitis tends to be much higher in AFLP than in HELLP
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16
Q

*How long after delivery can you present with eclampsia?

A

6 weeks

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17
Q

*5 RF for abruption

A

Maternal age younger than 20 or 35 years of age or older,
Parity of three or more,
Unexplained infertility,
History of smoking,
Thrombophilia,
Prior miscarriage,
Prior abruptio placentae,
Cocaine use.

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18
Q

*8 week pregnant G2P1; Vaginal bleeding, abdo Pain, HD stable. What are the 3 most important blood tests to order

A
  • CBC
  • BhCG
  • Group and screen
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19
Q

*Gestational sac is 18 mm and irregular. What are 3 things on your DDX.

A
  • Ectopic pregnancy
  • Incomplete miscarriage
  • Anembryonic pregnancy (blighted ovum >25mm)
  • Early IUP
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20
Q

*Her BHCG is 230,000. What is the most likely diagnosis.

A

Molar pregnancy

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21
Q

*4 causes cardiac arrest in pregnancy

A

BEAU-CHOPS
- Bleeding/DIC
- Embolism (cardiac/pulmonary/amniotic fluid)
- Anesthetic complications
- Uterine atony
- Cardiac disease: MI/ischemia/aortic dissection/cardiomyopathy
- Hypertension/pre-eclampsia/eclampsia
- Other: all the Hs and Ts of standard ACLS
- Placental abruption, previa
- Sepsis

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22
Q

*What three features define preeclampsia

A

• Pregnancy at 20 weeks gestational age or later
• Gestational hypertension (140/90 mmHg or higher and previously normotensive)
• Proteinuria (300 mg/24 hours) OR (new since 2013): other end organ damage –> thrombocytopenia; incrs LFTs, pulmonary edema, visual disturbance, AKI

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23
Q

*List five maternal complications of preeclampsia. What are 4 complications specifically for baby?

A

Eclampsia/seizures/death
- Heme: Thrombocytopenia, DIC,Elevated liver enzymes, LDH,HELLP (hemolysis, elevated liver enzymes, low platelets)
- Renal: Oliguria, renal failure
- Neuro: Headaches, visual disturbances, hyper-reflexia, stroke, seizures, convulsions
- Resp: pulmonary edema
- Abdo: Hepatic failure, jaundice
- Baby: placental abruption: bleeding, decreased fetal movement, IUGR, Oligohydramnios

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24
Q

*Most important questions to ask mother who presents crowning

A

1) Gestation Age (i.e. younger = need for NICU resus)
2) PROM bleeding (i.e. expected fetal distress on arrival due to bleeding, acidosis, hypoxia, multi-system insult)

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25
Q

*5 manoeuvres for shoulder distocia

A

HELPER pneumonic
H- call help
E- episiotomy
L- Leg’s up (McRobert; knee to chest position)
P- Pubic pressure (i.e. suprapubic)
E- enter the vagina (Rubins and Wood’s corkscrew). Rubin: pushing most accessible shoulder towards the fetal chest. Wood’s: impacted shoulder is release through rotation of the fetus 180 degrees
R- remove the post arm

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26
Q

*What are the 4 stages of labour

A

Stage 1: <10cm dilation, latent phase + active phase. The first stage of labor is the cervical stage, ending with a completely dilated, fully effaced cervix.
Stage 2: full dilation -> baby out. Fully dilated cervix and accompanied by the urge to bear down and push with each uterine contraction.
Stage 3: baby born -> delivery of placenta, frequent checks of the tone and height of the uterine fundus.
Stage 4: 1 hour post partum, critical period during which postpartum hemorrhage is most likely to occur.

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27
Q

*What are 3 causes of post partum hemorrhage? Which is most common?

A

“four Ts”— t one, t rauma, t issue, and t hrombin
Accounting for 75% to 90% of cases, the most common cause of serious immediate postpartum hemorrhage is laxity of the uterus after delivery.

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28
Q

*What are 5 physiological changes in pregnancy that are going to impact your intubation and mechanical ventilation?

A

40% increase in minute ventilation
Decreased vital capacity
Mild resp acidosis
Flared ribs - predisposition to PTX and faster progression to tension PTX
reduced oxygen reserve (FRC)
increased 02 consumption
increased oxygen demand during apnea by 30%
increase minute ventilation leads to hypocapnia (so a paCO2 of 35 is abnormal…!)
need RAPID RSI,
BVM is super tough, vent pressures higher
Delayed GI empyting - risk of asp.

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29
Q

*Trauma patient, pregnant, with profuse vaginal bleeding and FHR decreased. Presumed Dx?

A

Placental abruption

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30
Q

What is the discriminatory zone and when should an intrauterine pregnancy be visible on ultrasound?

A

Transvaginal: gestational sac should be visible once BHcG reaches 1500, or 5 weeks
Transabdominal: gestational sac should be visible once BHcG reaches 6500 or 6-8 weeks

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31
Q

List 3 differentials each for a lower and higher than expected BhCG

A

Lower: ectopic, abortion, inaccurate dates
Higher: multiple gestations, molar pregnancy, trisomy 21

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32
Q

When should an embryo with cardiac activity be visible on US

A

Transvaginal: 6 weeks BHcG >10,000 - 20,000
Transabdominal: 7 weeks, BHcG >20,000

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33
Q

What are 2 ultrasound criteria for embryonic demise

A

Intrauterine gestational sac >25mm with no embryo
CRL >7mm with no cardiac activity

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34
Q

List 5 sonographic criteria of an abnormal pregnancy via transvaginal ultrasound

A

No gestational sac when BHcG >3000, no yolk sac with gestational sac >13mm or 32 days LMP, no fetus with gestational sac >25mm, no fetal heart tones with 5 mm CRL, no fetal heart tones with gestational age 10-12 weeks

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35
Q

What qualifies a determinate scan for intrauterine pregnancy

A

Bladder uterine juxtaposition, centrally located gestational sac >25mm, yolk sac and/or fetal pole (double ring sign)
*gestational sac alone is not an IUP; can be a pseudogestational sac

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36
Q

What dose of Rhogam should be given in first trimester bleeds? In later trimesters?

A

120 uG, 300uG

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37
Q

A patient is diagnosed with an ectopic and is interested in medical management. What patient factors make this safe?

A

Hemodynamically stable, minimal abdominal pain, able to follow up reliably, have a tubal mass <3.5cm in diameter, no fetal cardiac activity, no sonographic signs of rupture, and have normal baseline liver function

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38
Q

List 10 risk factors for miscarriage

A

Increasing maternal or paternal age, maternal anatomic abnormalities (ex. Fibroids, uterine scarring, cervical incompetence), prior miscarriage, increased parity, vaginal bleeding in pregnancy, toxins (alcohol, cocaine), maternal infections, autoimmune disease, substance use, maternal comorbidities (poorly controlled diabetes, thyroid disease, obesity or low body mass)

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39
Q

Differentiate complete, incomplete, missed, threatened, and inevitable miscarriages

A

Complete: OS closed, tissue all passed, no FHR, no retained tissue, not viable
Incomplete: OS open, bleeding and cramping, no FHR, some retained tissue, not viable
Missed: OS closed, no symptoms, no FHR, fetal demise in utero, not viable
Threatened: OS closed, bleeding, FHR, viable but at risk
Inevitable: OS open, bleeding, +/- FHR, not viable

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40
Q

What is a molar pregnancy? What are 4 clinical presentation features?

A

Proliferation of chorionic villi. Complete: fertilization of ovum with no maternal DNA. Partial: fertilization of ovum with two sperm. Presents with bleeding, hyperemesis, abnormally high bHcG levels, ‘snowstorm’ appearance on ultrasound

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41
Q

What is placental abruption

A

Separation of the placenta from the uterine wall, due to spontaneous hemorrhage or traumatic separation

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42
Q

List 5 complications of placenta abruption

A

DIC (due to fibrinogen drop), fetomaternal transfusion, amniotic fluid embolism, fetal death c/o impaired blood flow, maternal death c/o coagulopathy

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43
Q

List 5 risk factors for placenta previa

A

Increased maternal age, smoking, multiparty, C section, prior miscarriage, preterm labour

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44
Q

How would you differentiate between placental abruption and placenta previa

A

Pain, ultrasound (for previa), fetal distress

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45
Q

What is an abnormal blood pressure in pregnancy

A

> 140/90 (severe if >160/110)

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46
Q

What is gestational hypertension

A

BP> 140/90 diagnosed after 20 weeks gestation without proteinuria or signs of end organ dysfunction

47
Q

What is eclampsia

A

Preeclampsia + seizures

48
Q

List 4 antihypertensives that should be avoided during pregnancy

A

ACE, ARB, BB in T1, prolonged nitroprusside (fetal cyanide)

49
Q

What are 3 signs of magnesium toxicity and what is the antidotes

A

Decreased reflexes, respiratory depression, hypotension (other side effects: nausea/vomiting, weakness, bradycardia)
Calcium gluconate 1-2 amps IV

50
Q

What are 5 potential precipitants of an amniotic fluid embolism

A

Abortion, miscarriage, spontaneously, uterine contractions in labour (most common), amniocentesis, placental abruption

51
Q

List 5 differentials for abdominal pain in pregnancy

A

Obstetrical: miscarriage, septic abortion, ectopic, chorioamnionitis, preeclampsia, placental abruption
Gynecologic: corpus luteum cyst, ovarian torsion, PID
Non gynecologic: appendicitis, cholecystitis, hepatitis, pyelonephritis

52
Q

List 3 differentials for jaundice in pregnancy

A

Cholestasis of pregnancy, hepatitis, acute fatty liver

53
Q

Name two risk factors for acute fatty liver of pregnancy

A

Primis, twin pregnancy

54
Q

List 3 lab abnormalities that can be expected in hyperemesis gravidarum

A

hypokalemia, hypomagnesemia, hypochloremic metabolic acidosis, ketonuria

55
Q

List 5 medications that can be used in the treatment of hyperemesis

A

Ginger 250 mg PO Q6, Diclectin (Pyridoxine/Doxylamine 10mg/10mg tabs), Diphenhydramine, Metoclopramide, Ondansetron

56
Q

Describe the use of D dimer in pregnancy, citing relevant literature

A

Pregnancy adapted YEARS
van der Pol LM, et al. N Engl J Med. 2019 Mar 21;380(12):1139-1149
Population: 510 pregnant patients >18 in the ED or obstetrical ward for ?PE
Intervention: YEARS algorithm. If all criteria negative 1) signs of DVT 2) patient have hemoptysis 3) PE most likely diagnosis a higher D dimer threshold of 1000 can be used. CTPA or US was then ordered for further workup as needed
Control:
Outcome: Incidence of symptomatic VTE in 3 mo follow up -> PE was ruled out in 96% of patients, 1 patient was diagnosed with a popliteal DVT on day 90. Secondary outcome includes proportion of patients who did not require a CT based on algorithm -> 39% avoided a CT scan.
Limitations: not exclusively an ED population, results of D dimer may have been known to clinicians
Bottom line: Pregnancy adapted years can be safely used to rule out PE

57
Q

What is the preferred anticoagulant for thrombosis in pregnancy

A

Low molecular weight heparin (do not cross the placenta)
LMWH preferred over UFH as lower risk of osteoporosis, lower rate of bleeding

58
Q

List 2 antibiotics, commonly used in the treatment of UTIs, that should be avoided in pregnancy

A

Nitrofurantoin should be avoided in T1 (teratogenic) and late pregnancy (hemolytic anemia)
Septra should be avoided in TQ (teratogenic) and late pregnancy (kernicterus)
Fluoroquinolones should always be avoided (cardiac toxicity)

59
Q

List 5 infectious diseases and their associated congenital abnormalities in pregnancy

A

TORCH
Toxoplasmosis: Associated with raw meat, cat feces. Results in chorioretinitis, hydrocephalus, mental disorders, seizures, jaundice
Other - Syphilis: Congenital syphilis; hepatosplenomegaly, osteochondritis, jaundice, Hutchinson’s teeth
Other - Parvovirus: anemia, hydrops, miscarriage
Rubella: hearing loss, cataracts, heart disease, hepatitis
CMV: Associated with day care workers, moms often asymptomatic. Results in hydrocephalus, microcephaly, deafness, chorioretinitis
Herpes Simplex V: disseminated herpes in newborns, encephalitis

60
Q

List 3 methods of HIV transmission to the newborn

A

Antepartum, intrapartum (consider C section), post partum (breast feeding)

61
Q

List 5 factors that increase the risk of HIV transmission to the newborn

A

Viral load, breast feeding, mode of delivery (SVD vs. C section), prolonged ROM, antiviral medications

62
Q

List modifications to HAART for pregnancy patient

A

Should include zidovudine (AZT), avoid efavirenz (EFV)

63
Q

List 3 physiological changes to the heme system that occur during pregnancy

A

Increase in circulating plasma volume (dilutional anemia)
Increase in leukocyte count, but impaired immune function (autoimmune disease improve)
Decrease in platelet count, but overall increase in clotting factors and hypercoagulability

64
Q

List 4 ddx for anemia in pregnancy

A

Dilutional, iron deficiency, folate deficiency, sickle cell

65
Q

List 6 risk factors for the development of folate deficiency in pregnancy

A

Multiple gestations, anticonvulsant medication, malnutrition, hyperemesis, alcoholism, poor leafy green intake

66
Q

List 3 physiological changes to the cardiovascular system in pregnancy

A

Resting HR increases (due to decrease in BP mid pregnancy)
Increase in cardiac output
ECG changes: T wave flattening, T wave inversions in lead III, lead axis deviation, short PR, increased HR

67
Q

List 4 differentials for chest pain in pregnancy

A

ACS, PE, aortic dissection, SCAD, vasospasm, biliary colic

68
Q

List 3 changes to the management of ACS in the pregnancy patient

A

Avoid hypotension with nitrates
Avoid beta blockers in T1
Caution with thrombolysis in late pregnancy, this will prevent surgery or epidural anesthesia. Caution if dissection is suspected

69
Q

List 3 physiological changes to the respiratory system during pregnancy

A

Increased tidal and minute volume
Respiratory alkalosis (pCO2 28-32, pH 7.40-7.45) with a chronic metabolic compensation through lower bicarb
Decreased in inspiratory and expiratory reserves due to displacement of the chest

70
Q

List 4 common maternal adverse outcomes that result from chronic medical disease during pregnancy

A

Preterm labour, prematurity, PROM, need for C section, pre-eclampsia

71
Q

List 4 common fetal adverse outcomes that result from chronic medical disease during pregnancy

A

IUGR, fetal loss, preterm delivery, low birth weight (exception diabetes), fetal hypoxia (asthma)

72
Q

What 3 interventions should you avoid in a pregnant patient with thyroid storm

A

Methimazole (PTU preferred), Iodide (will destroy fetal tissue, hydrocortisone is sufficient), radioactive ablation (destroys fetal thyroid)

73
Q

List 3 unique complications of pregnancy in a patient with a spinal cord injury

A

DVTs, UTIs, autonomic dysreflexia (must be higher than T5-6), masked labour (must be higher than T10)

74
Q

When is a fetus most sensitive to drug effects

A

Organogenesis, day 21-56, week 3-8
CNS is most affected during weeks 10-17

75
Q

A woman at 32 weeks presents with a chronic pain. What is the ideal analgesia? List 2 agents that should be avoided and explain why

A

Tylenol
NSAIDs are avoided in 3rd trimester (tocolytic) and 1st trimester (risk of spontaneous abortion, cardiac septal defects), premature closure of ductus arteriosus)
Opioids should be avoided near term due to respiratory depression of the infant and neonatal abstinence syndrome
Ergotamines

76
Q

What is fetal warfarin syndrome

A

Dose dependent, highest risk weeks 6-9, may result in corpus callosum agenesis, hypoplasia of nasal bones, optic atrophy and blindness, CNS malformations, fetal intraventricular hemorrhage, stillbirths, spontaneous abortion

77
Q

Name one antidote contraindicated in pregnancy

A

Methylene blue: can cause hemolytic anemia, hyperbilirubinemia, methemoglobinemia, jejunal atresias

78
Q

List 3 antibiotic classes preferred in pregnancy

A

Cephalosporins, penicillins, macrolides (ex. azithromycin), metronidazole

79
Q

List 3 antibiotic classes avoided in pregnancy

A

Fluoroquinolones (cardiac defects during T1), sulfa (hemolytic anemia, kernicterus, neural tube defects), tetracyclines (fetal bone development, teeth discolouration, Aminoglycosides

80
Q

What is the preferred antifungal agent in pregnancy? What drug should be avoided

A

Nystatin is preferred
Fluconazole should be avoided due to craniofacial and cardiac defects. Okay if given intravaginally

81
Q

Name one antiarrhythmic that should be avoided in pregnancy

A

Amiodarone (congenital abnormalities esp. thyroid, has a high concentration of iodine)

82
Q

What is the vasopressor of choice in pregnancy

A

Phenylephrine

83
Q

List 10 known teratogens

A

Isotretinoin, warfarin, methotrexate, methylene blue, phenytoin, valproic acid, rosuvastatin, simvastatin, NSAIDs in 3rd trimester, sulfonamides, tetracyclines, fluoroquinolones

84
Q

List 3 reassuring findings on fetal heart tracing

A

Rate 110-160, moderate variability (5-25 bpm), accelerations

85
Q

List 3 concerning findings on fetal heart tracing

A

Rate <110 or >160, minimal, marked or sinusoidal variability, late decelerations

86
Q

List 3 maternal and 3 fetal findings that can affect fetal heart tracing

A

In general FHR is used as a surrogate for fetal oxygenation status
Maternal: respiratory status, smoking, positioning, anemia, hypotension, placental abruption, chorio
Fetal: cord compression, acidemia, oligohydramnios, drugs

87
Q

What causes 1) early 2) variable and 3) late decelerations

A

Early: head compression, transient
Variable: cord compression
Late: uteroplacental insufficiency

88
Q

List 3 maneuvers that can be used to help manage a cord prolapse

A

Knees to chest, elevate presenting part (ex. head down in Trendelenburg), tell mother to refrain from pushing, Foley + 500-750 ml of warm saline into the bladder to help lift the fetus off the cord

89
Q

Describe the maneuvers used to deliver a baby

A

Deliver the head -> gentle downward traction on the head to deliver the anterior shoulder -> gentle upward pull on the anterior shoulder for the posterior shoulder -> clamp and cut the cord

90
Q

List the components of the APGAR score

A

Activity: 0 absent, 1 arms and legs flexed, 2 active
Pulse: 0 absent, 1 <100, 2 >100
Grimace: 0 none, 1 grimace, 2 sneezing/coughing/pulling away
Appearance: 0 blue/gray, 1 normal except at extremities, normal over body
Respirations: 0 none, 1 slow/irregular, 2 good/crying

91
Q

Baby comes out, grimacing and with arms and legs flexed, but HR >100, normal colour, and crying. What is the baby’s APGARS

A

8

92
Q

List 4 etiologies for labour dystocia

A

Power (hypertonic contractions), Passenger (fetal position, large size), Passage (pelvic structure), psyche (anxiety/pain)

93
Q

List 4 risk factors for shoulder dystocia

A

Maternal: previous shoulder dystocia, operative delivery, diabetes, obesity, narrow pelvis
Fetal: macrosomia, postmaturity, erythroblastosis fetalis

94
Q

List 4 complications of shoulder dystocia

A

Maternal: perineal and sphincter tears, urinary incontinence
Fetal: brachial plexus injuries, clavicle fractures, hypoxic brain injuries

95
Q

Name 1 manuever that can help in a breech presentation

A

Maurice maneuver: Place fingers on maxillary sinuses to help guide the head; flex the fetal neck and draw in the chin - do not pull

96
Q

What is the definition of postpartum hemorrhage

A

> 500 cc via vaginal delivery, >1 L after C section, any amount of bleeding that causes hemodynamic instability

97
Q

List 4 medications that can be used in the management of postpartum hemorrhage

A

Oxytocin (prolonged half life) 10 U IM after the delivery of the anterior shoulder (a second dose or 20-40U in IL NS wide open or 5-10 US IV bolus over 1-2 mins)
Misoprostol (800 mcg PR, PO, or SL)
Ergotamine Ergot (0.25mg IM or IV, may repeat 2-4H intervals
Prostaglandin Hemabate/Carboprost (0.25mg IM x 8 q 15 min; can be injected directly into the uterus), prostaglandin
Tranexamic acid

98
Q

List 3 physical maneuvers that can be done in a woman with postpartum hemorrhage

A

Tamponade with bimanual massage, uterine packing, remove clots/placenta tissue, Bakri balloon, Blakemore balloon, Foley with 80 ml of NS

99
Q

Describe the evidence for TXA in postpartum hemorrhage

A

WOMAN trial
Population: 20,060 women were enrolled in 23 countries. Randomized, placebo controlled trial
Intervention: 1g IV TXA or matching placebo, w a 2 dose if bleeding continued for > 30 mins
Control: placebo
Outcomes: No change in original primary outcome; death from all causes of hysterectomy. 2ndary outcomes include death due to bleeding was significantly decreased in the TXA group (1.5 vs. 1.9%). This was the revised outcome
Bottom line: -ve trial as originally designed. Small effect but no adverse effects and inexpensive drug; worth considering

100
Q

List 8 risk factors for premature labour

A

Maternal: short cervix, placenta previa, placenta abruption, extremes of age, prior preterm birth
Baby: multiple gestation, antepartum hemorrhage, PROM, polyhydramnios, fetal hydrops, congenital abnormalities of the fetus, cervical incompetence
Pre-existing: hx of preterm birth, smoking, infection, HTN, GDM, previous surgery, substance abuse, psychosocial stressor

101
Q

What is the criteria for fetal viability

A

24-46 weeks, EFW 500g [Rosens]
22 weeks [SOGC]

102
Q

Describe the changes in vitals that can be expected in the pregnant patient

A

HR increases by 10-15 beats, BP lowers by 5-15 by the second trimester (normal by the third trimester)

103
Q

Describe an important modifier for the pregnant patient during CPR

A

Uterine displacement to the left

104
Q

What is the clinical presentation of placental abruption

A

Little to no signs of external injury. May present with vaginal bleeding, pain, uterine tenderness, and fetal distress (fetal distress is the most sensitive sign). Risk of DIC. Most common cause of fetal loss

105
Q

List 5 side effects of trauma in the pregnant patient

A

Placental abruption, uterine contractions, uterine shock, amniotic fluid embolism, fetomaternal hemorrhage, direct fetal injury, DIC

106
Q

What is the most common side effect of trauma in the pregnant patient

A

Uterine contractions

107
Q

Describe modifications to ATLS in the pregnant patient

A

Airway: assume difficult intubation, pre-oxygenation, increased risk of aspiration
Breathing: chest tubes should be higher, vent settings should be adjusted for tachypnea of pregnancy (target PaCO2 of 30)
Circulation: place patient in in left lateral decubitus, physiologic increased cardiac output. Solid organs are all displaced upwards and maybe more vulnerable to injury. Avoid vasopressors (decreases flow to the placenta)

Assessment of the baby does not come until secondary survey (fetal heart tones, no digital exam)

108
Q

How long should the pregnant patient be observed post trauma

A

4 hours of fetal monitoring with NST. Should be extended to 24 hours if uterine tenderness, abdominal pain, vaginal bleeding, uterine contractions, rupture of membranes, atypical or abdominal fetal heart rate, high risk injury, low serum fibrinogen

109
Q

What additional blood work would you order in a pregnant trauma patient

A

Kleihauer-Betke, blood/Rh type, coags, fibrinogen (high risk of DIC)

110
Q

What is the dose of Rhogam? When should it be given?

A

50mcg (DID WE DECIDE ITS 300? SOURCE?) in 1st trimester, 300mcg after than, should be given within 72 hours
300mcg in all traumas regardless of first trimester as per SOGC

111
Q

Describe the process of a resuscitative hysterotomy

A

Indications: ACLS for 4 minutes with uterus >umbilicus
1. Continue CPR with the mother throughout the resuscitative hysterectomy
2. Large incision for epigastrium to symphysis through the peritoneum
3. Vertical incision in the uterus (thinner in lower segments) or try using scissors
4. Fundal pressure, deliver baby, clamp and cut cord
5. Take the placenta out
5. Pack/close the uterus. Postpartum hemorrhage management

112
Q

What are expected ECG changes in pregnancy

A

Left axis shift, flattering of T waves, Q waves in lead III

113
Q

What is a safe radiation dose to the fetus

A

50 mGy (all scans <50 mGy) this is a 2% lifetime risk of cancer with no evidence of fetal malformation

KChan Saves the World (24 decks)

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